(Adapted from the Peace
Corps Volunteer Safety Council, January, 1998)
A) Pre-Assault Preparations
1) Administrative Considerations
a) Be informed about legal requirements and procedures. The Resident
Director and designated medical doctor could establish an easily accessible
file that contains a memorandum or other documents describing in detail
current local forensic medical requirements and legal procedures for prosecution
of the alleged assailant in the case of a rape or attempted rape. The documents
should address how rape is locally defined in that country, what constitutes
the requisite forensic material, who can collect forensic material, how
the forensic material must be handled to preserve its value, and the timing
required for collection of the material and other evidence as well as the
statue of limitations for prosecution. This information can be gathered
through a consultation with local counsel as discussed below. (See also
"Questions for Local Counsel".)
The resident Director should be familiar with the general requirements
for prosecution and for gathering evidence, since it is his or her responsibility
to have in-depth and up-to-date knowledge of these requirements. Also these
requirements should be verified and updated annually.
b) Identify a local attorney for consultation. The Resident Director
could identify a local attorney who can be contacted for emergency consultation
and who can provide knowledgeable and experienced criminal attorney. The
U.S. Embassy may have a list of local attorneys available for this purpose.
Every attempt should be made to build and maintain a relationship with
an attorney before a crisis occurs. The attorney's name address and telephone
numbers (office and home) should be kept with the forensic and legal information
collected and updated annually. The resident director could also obtain
a referral to and meet with a criminal lawyer before any assault occurs,
for aid in compiling the specific information described above. (Again,
see "Questions for Local Counsel")
2) Student and Staff Training
a) Address assault prevention at the Pre-departure Orientation and
at the Orientation. Both orientations could address assault prevention.
The Resident Director and the Director for the Women's Center, etc. could
work together to develop appropriate training strategies.
The safety and security needs of all students, the issue of confidentiality,
and to urge prompt notifications to staff in case of rape and attempted
rape could be discussed. Students should be made aware of the notification
protocol. Their attention should be drawn to the obligation of a staff
person who receives a report of a rape or attempted rape to report it immediately
to the designated medical doctor. And the importance of such reports to
preserving the safety of other students. They should also be advised of
the fact that other staff members may have to be informed of the rape's
location and pertinent circumstances, also in order to protect other students.
The victim's name will be protected to the maximum extent possible.
b) Emphasize the importance of notification. It is important
that a victim tell someone on the staff of a rape, so that she or he can
receive appropriate support. It is also important to report an incident,
so that staff can work to identify any steps available to reduce the risk
to other students. For example, some areas of country (e.g., certain beaches,
hostels or hotels) may be deemed unsafe as result of the report, and students
should be so advised. These practical and positive results of notification
should be emphasized in training.
B) IMMEDIATELY AFTER REPORT
1) Providing support to the victim.
a) Medical decisions. Medical decisions should be made with the
help of a medical professional in the host country, the on-site resident
director, and the study abroad administrator at the home institution in
consultation with a medical professional at the home institution. The desires
of the victim should be taken into account in any actions. Institutional
policy and privacy issues may guide the amount of interaction with the
victim's family and significant others.
b) What to communicate to the victim. All involved staff should
give the victim, verbally and non-verbally, three messages:
I believe you;
You are not alone; and
We are sorry this happened to you
It is especially important never to blame the victim. Rather, staff
should ask, "What can we do to help you?" The "victim"
of rape will at some point also become a "survivor" of rape;
staff should be cognizant of this transition. Host country staff unfamiliar
with these issues may benefit from special training or discussion of supportive
techniques. (A more complete discussion of the issues related to supporting
the victim is contained in "Understanding and Supporting the Victim
of a Rape.")
2) Keep notes of the report and all developments.
The Resident director could keep extensive and complete notes on the
case because he or she will need to refer to them as the fog of memory
thickens over time. The assaulted student should not be referred to by
name in the notes; initials should be adequate.
3) Assessing the safety of the victim and other students.
The Resident Director could do the following to assure the safety
of the victim and other students:
a) Make sure the victim is safe and feels safe. The Resident
Director may consult with the victim, the US Embassy's Regional Security
Officer (RSO) and others to determine how best to ensure the actual safety
of the victim. The victim must also feel safe, however, and the Resident
Director could take steps to allay the victim's fears to the extent possible.
1. In unusual cases, a security guard may be required at the location
where the student is staying-possibly at the hospital. The Resident Director
could authorize this expenditure. The RSO may need to be involved with
2. If the student's life is judged to be in danger for other than medical
reasons, the Resident Director may institute emergency evacuation procedures
to remove the victim from the country. The Resident Director could authorize
b) Assess any possible risk to other students and staff. If there
is any reason to believe that other students or staff are at risk, the
resident Director could immediately take appropriate action to ensure their
4) Preserving the option to prosecute
a) Advise the victim of his or her legal rights and how best to preserve
the option to prosecute. The Resident director is responsible for ensuring
that the student has been advised of his or her legal rights, of the need
for evidence, and other elements of preserving the option to prosecute.
Local law may require that certain evidence be gathered and legal procedures
be followed within a specified time frame after the assault; failure to
carry out these procedures or to collect the evidence in a timely way could
preclude prosecution at the later date. The possibility of prosecution,
even though a final decision may not be made for some time thereafter.
At all stages of investigation and prosecution, it is the victim's decision
whether to participate in the legal proceedings; the victim cannot be compelled
to participate in a prosecution.
b) Advise the victim of the public nature of the criminal proceedings.
The victim should be advised that, if she or he decides to prosecute, the
records will become public knowledge as the case proceeds though the judicial
system. (The Resident Director should determine if there are any limits
on this general rule in the applicable jurisdiction.)
c) Preserve the evidence to the extent possible. The student's
physical and mental health take precedence over a prosecution. Consistent
with this understanding, however, the Resident Director and medical doctor
should take immediate steps, to the extent they are able, to preserve clothing
and any other relevant material for tests. (Physical evidence that must
be obtained from the victim can only be obtained with the victim's consent,
of course.) Because of the legal issues related to chain of custody, such
material should be maintained under lock and key. Consult local counsel
for specific rules applicable in the jurisdiction.
d) If prosecution seems likely, retain local criminal counsel on
behalf of the Student
5) Notification of US home institution
6) Notification of Embassy personnel
a) The Resident Director notifies RSO in accordance with protocol or individual
understanding with RSO. As reflected in the notification summary, above,
the Resident Director could promptly notify the RSO of the incident and
location, but should not give the name of the victim.
b) Resident Director notifies Ambassador. The Resident Director should
also inform the Ambassador of the assault, without giving the name of the
student. Notification should be especially prompt if the victim wishes
to prosecute or if the incident is likely to assume a high profile.
7) The Press
The Resident Director, in consultation with the Regional Director (if
one exists) and US home institution Director, could discuss any press-related
issues in-country with the Ambassador and/or the United States Information
Service (USIS) public affairs officer. The Study Center staff should always
encourage the press not to use the name or the initials of the student.
C) AFTER THE IMMEDIATE CRISIS
1) Providing support to the victim
a) Continue to provide emotional support to the victim. Consult
the section called "Understanding and Supporting the Victim of a Rape"
for a detailed description of the continuing issues related to the emotional
state of the victim of a rape.
b) Urge the victim to agree to accept a suitable companion for a
while. The Resident Director should urge the student to accept a suitable,
constant companion who may be staff or another student of the student's
choosing. The companion need not-and usually will not -be the Resident
Director. The Resident Director could make every attempt to provide a suitable
and constant companion for the victim, including in a hospital setting.
c) Offer other practical support to the victim. The resident
Director could offer practical as well as emotional support to the victim.
Practical support could include identifying and hiring a confidential interpreter;
making oneself available (but not requiring) to accompany the victim to
attorney meetings, depositions, examinations, suspect identification and
other legal proceedings. Other useful support may include offering to obtain
cash for expenses; providing clothes; providing a trip to the site to pick
up belongings; finding a nice and safe place to stay temporarily; offering
an escort to the site; making available at the Study Center expense phone
calls to parents or other supportive individuals; offering to contact and
obtain the company of other students who can provide support.
d) Support a decision to medevac. If the student is to be medevaced,
the Resident Director should give full support to that decision and should
not preclude future discussions about the student's subsequent return to
e) Support the Student's family. The Resident Director should
have the responsibility for supporting the student's family.
2) Communications between the study center and the US home institution.
a) The US home institution will designate a primary contact person
at the home institution for use by US home institution in contacting the
study center. One person in the US home institution will be designated
the contact person. That person's task is to coordinate and centralize
non-medical calls to the study center about the incident and to maintain
one channel of communication. This is important to avoid confusion about
the facts of the incident and the status of the matter. Regular, scheduled
telephone calls between the study center and the US home institution to
update those individuals with a need-to-know can be productive and can
reduce the burden placed on the study center by repetitive calls from the
US home institution.
b) Resident Director sets up direct telephone consultations with
the US home institution as he or she needs. The Resident Director should
call the US home institution staff directly as needed to receive specific
information and counseling e.g. legal advice from university attorneys
or investigate advice from the Study Abroad Director.
c) Press Coverage. The Resident Director should update the Office
of Congressional relations and the Press Office regarding any press coverage
in-country or in the US.
3) Involvement of Embassy personnel
a) Work with the RSO. The Resident Director could work with the
RSO to ensure that the victim's needs and wishes are addressed and respected
during any investigation or prosecution that results from the incident.
They could also attempt to ensure that the victim is provided a confidential
interpreter, an appropriate attorney, and is accompanied to any attorney
or investigative meetings, suspect identification or legal proceedings
(if the victim so desires).
b) Keep the Ambassador and USIS posted if there is press coverage.
If the case has a high profile, the Ambassador and the USIA should be kept
up-to-date on developments in the case. USIA can often work with the local
press to reduce or suspend coverage, and to keep the name of the victim
confidential, if there are compelling reasons for such a request.
c) The level of Embassy involvement can be expected to vary from
incident to incident. The level of discussion and focus on the incident
within the mission will vary, depending on how the mission collectively
perceives the incident, e.g., if one or more other members of the program
are concerned about their own well-being, there may be greater involvement.
d) Written communications should NOT contain the name of the victim.
No cable or fax communications by the Resident Director, RSO or other embassy
staff related to the incident should contain the victim's name.
4) Health and Security of Students and Staff
a) Work as a team at the Study Center, but preserve confidentiality.
Given the many and possibly competing priorities in such a crisis, the
Resident Director and staff should work as a team, holding regular update
meetings to keep the team informed, while at the same time preserving the
confidentiality of information unnecessary for the team to know.
b) Provide support to other students and staff. The resident
Director should be aware that rapes and attempted rapes are potentially
traumatic for others in addition to the actual victim. The Resident Director
and other staff should be particularly aware that other students and staff
may have been past victims of rape or attempted rape and may have special
needs as a result of the assault and require additional support. This support
will most often be sought from staff. For example some students may react
to the incident without identifying the reaction as tied to the assault.
(The document entitled "Understanding and Supporting the Victim of
a Rape," contains relevant material related to delayed reactions that
may be of use in considering how best to handle certain other students.)
c) Provide emotional support for staff. Supporting a rape victim
is often stressful for the staff involved. The resident Director should
be prepared for this possibility and offer or seek support as needed. The
service of the State Department Regional Psychiatrist can be helpful in
some circumstances for US staff. The Office of Special Services is also
available to render support to staff.
d) Consider using State Department Training Resources as part of
the response. The Mobile Training Team, which gives rape prevention
and assault prevention training can be requested through the RSO. Such
training can be a useful response to an assault that causes widespread
5) During an investigation and prosecution
a) Consult with US home institution Study Abroad Director. During
an investigation and prosecution, the Study Abroad Office is available
to provide professional advice and guidance with respect to legal questions
and investigative matters.
b) Retain and consult with local criminal lawyer. The Resident
Director should identify and retain a criminal lawyer who is experienced,
well-respected in legal and judicial circles, and able to manage and explain
the intricacies of the local legal system to the student and to the Resident
Director. This retention should be accomplished in consultation with the
Study Abroad Center at the US home institution. Do not forget to consult
the list of legal questions to discuss with local counsel.
c) Resident Director serves as the US home institution's point person
for investigation and prosecution. The Resident Director should serve
as the point person within the university. If the victim has left the program,
completing the investigation may require a significant time commitment
on the part of the Resident Director. It may also require support form
the US home institution for contact with the victim, if she or he returns
to the US.
d) A medically separated victim may return to the country, at the
program's expense to provide testimony. A student who has been medically
separated may return to the country at the program's expense to testify
in a prosecution. The (former) student's travel should be coordinated through
the US home institution.
e) Consider security implications of prosecution (and non-prosecution)
for the victim, other students and staff. The Resident Director should
consult with informed persons about whether prosecution (or failure to
prosecute) and conviction (or failure of convict) would have any significant
security implications for the victim or for other students. (For example,
will family members of the perpetrator be inclined to take any retaliatory
f) An outgoing Resident Director should ensure that an acting Resident
Director or incoming Resident Director is fully informed about a prosecution
or conviction. After completing the responsibility as a Resident Director
or Program Director, in which a rape has occurred, an outgoing Resident
Director/Program Director should ensure that the records of the incident
are complete and current. He or she should also ensure that the acting
Resident Director and the incoming Resident Director are fully briefed about
the status of the case, including any sentence after conviction, and whether
release of the assailant is pending. Such briefings may need to occur over
the period of a number of years with each new Resident Director, depending
on the length of any sentence that has been imposed on a convicted assailant.
To establish procedures for the appropriate medical and legal management
of students who have been sexually assaulted.
Sexual assault is defined as any non-consentual sexual act and is a form
of violent crime. Rape, attempted rape, or any unauthorized contact with
genitals, breasts, or mouth should be reported to the Resident Director
and managed as a sexual assault.
Victims of sexual assault do not always present at the time of the incident,
but may present at a later date with incident-related symptoms (e.g. anxiety/depression,
pregnancy, STD.) Individuals (men and women) who report that they have been
sexually assaulted should be treated in a compassionate, non-judgmental
manner (see "Sexual Assault: Counseling.")
It is estimated that one in every six women is raped during her lifetime.
It is the court's responsibility to decide if the legal definition of rape
applies in a particular case. The responsibilities of the designated medical
doctor when managing a reported rape should be to:
- Assure the victim's physical safety.
- Document the pertinent history.
- Perform a careful physical examination.
- Promptly treat physical injuries.
- Inform the Resident Director of the assault.
- Maintain medical confidentiality.
- Contact the US home institution doctor.
- Provide and /or arrange psychological support (see "Sexual Assault:
- Prevent sexually transmitted disease.
- Prevent unwanted pregnancy.
- Collect legal evidence.
C) CLINICAL MANAGEMENT
Students who have been sexually assaulted should be encouraged to go
to a hospital/clinic as soon after the assault as possible. Students reporting
rape should be asked not to urinate, defecate, rinse their mouths, or clean
under their fingernails before examination, if possible. Inform the student
that this request is to help obtain evidence which might later be used in
court and is not in itself for medical reasons.
The designated doctor should tend, first and foremost, to the well-being
of the student. The student should be taken to a quiet, comfortable, safe
area and not be left alone. The student may prefer to be accompanied by
a friend. Male doctors should arrange for a female chaperon when examining
women. Consent must be given before examination and treatment. This also
allows the student a sense of control over the examination.
Information should be carefully recorded in the student's medical record,
with the history reflecting only the victim's account of the incident. For
serious sexual assault or rape, a comprehensive history and examination
are required (see below), with special attention to physical injuries, emotional
distress, and the collection of appropriate evidence for future legal proceedings
(see section 6.)
MANAGEMENT OF SERIOUS SEXUAL ASSAULT
History should include:
- Age and identifying information of the victim and the alleged assailant
- Date and time of the assault and examination
- Circumstances of the assault
- Details of the sexual contact (oral, vaginal, or anal intercourse,
ejaculation or urination by the assailant)
- Type of physical abuse (use of weapons or restraints, drugs, alcohol)
- Victim's activities after the assault (change of clothing, bathing,
douching, urination or defecation)
- Gynecological history:
Last menstrual period
Recent gynecological surgery or infections
Last voluntary sexual experience
Examination (see section 6 for more detail)
Carefully examine the entire body. Take photographs or make drawings
of injured areas.
External (total body):
- Injuries resulting from oral penetration
- Hair combing
- Hair sample
- Vaginal secretions
- Check for gynecological pathology, trauma, and foreign objects
Culture for chlamydia (cervix) and gonorrhea (cervix, rectum, and/or
pharynx, as appropriate) when possible. Non-culture testing is of limited
Test for syphilis and repeated in 3 months
Counsel and test for HIV; repeat in 6 months
Perform pregnancy test
Assess the need for:
- Medical treatment/medevac
- Pregnancy prevention
- Hepatitis B prevention
- Psychological/psychiatric care. Medevac is generally recommended, but
may not be immediately accepted by the student.
- Do not leave victim alone
- Notify US home institution doctor
- Arrange for medical treatment/medevac
- Provide STD & pregnancy prevention
- Arrange for close follow-up; continue to offer medevac (in most cases)
and monitor for sequelae.
- Arrange subsequent periodic visits
- Arrange an emergency contact and support person
- Schedule follow-up at 3 months for syphilis testing and 6 months for
D) PREVENTION OF PREGNANCY
Pregnancy occurs as a result of rape in about five percent of female
victims. Treatment to prevent pregnancy should be offered to victims, and
prescribed only after a pregnancy test has been performed to rule out prior
pregnancy. Following are the recommended doses of oral contraceptive pills
to be taken within 72 hours of the alleged rape.
Protocol for post-coital contraception
(must be taken within 72 hours of intercourse, obtain a negative pregnancy
Two doses of two (2) contraceptive tablets containing 50mcg estrogen
12 hours apart or Two doses of three (3) oral contraceptives tablets containing
35mcg estrogen , 12 hours apart.
Promethazine (Phenergan) 25mg suppositories (2)
Tigan 200mg suppositories (2) (to be used every 3-4 hours for nausea, if
E) PREVENTION OF SEXUALLY TRANSMITTED DISEASES AFTER
Few studies are available which predict the risk of acquiring a STD as
a result or rape.
E.1. CHLAMYDIA, GONORRHEAS, AND TRICHOMONAS
Treatment for the prevention of chlamydia, gonorrhea, and trichomonas
Recommended regimen to prevent gonorrhea, chlamydia, and trichomonas
Ceftriaxone 125mg IM in a single dose
Doxycycline 100mg orally 2 times a day for 10 days
Azithromycin 1 gm orally in a single dose
Metronidazole 2 gm orally in a single dose
Trinidazole 2gm orally in a single dose
E.2 Prevention of Hepatitis B
Rape victims who are non-immune to hepatitis B should receive prophylaxis
against hepatitis B. Unless the student has received a complete hepatitis
B vaccine series or is immune due to prior hepatitis B infection (serologically
confirmed), vaccination should be provided. Hepatitis B vaccine, when started
within 14 days of exposure, is effective. Hepatitis B Immune Globulin .06ml/kg
IM (HBIG human) can be given if available and offers additional protection.
Recommended post exposure immunization for hepatitis B (within 14 days
of exposure, no prior immunity).
Hepatitis B vaccine 1.0 ml IM (deltoid) at months 0,1,6
The risk of acquiring HIV infection as a result of rape depends on the
likelihood of the assailant having HIV, the sexual acts performed, and other
factors (associated trauma, presence of other STD's, etc.) The estimated
risk of HIV transmission in sexual assault by an HIV infected person (vaginal
or anal intercourse, or exposure to ejaculate) is about 2 per 1000. The
risk is higher if other factors are present.
No preventative treatment is available.
F) COLLECTING FORENSIC EVIDENCE
Physical evidence useful during legal proceedings includes the presence
of semen, genital and other injuries, and pubic hair obtained from medical
examinations. Evidence should be collected and handled in a manner acceptable
to local courts. Procedures standard in the U.S. for handling evidence are
generally acceptable (see below.) However, doctors should be familiar with
local laws and procedures and should adapt U.S. procedures to conform with
Following are standard procedures for collecting evidence during a rape
- Maintain a log of evidence collected. Anyone who handles the evidence
should sign and date the log indicating when they had possession of the
item and how it was stored.
- Avoid contamination by allowing only the victim to handle her clothing. Send
all of the victim's clothing (if she has not changed) to crime laboratory
in sealed and labeled paper bags.
- Prepare careful and complete photographs and /or drawings of the physical
- Examine the perineal and thigh area with a Wood's lamp to detect semen
- Comb the pubic hair over a sheet of paper (for possible material traceable
to the assailant), and pluck and store a few of the victim's pubic hairs.
- Perform a vaginal examination with speculum lubricated only with water.
Note the condition of the hymen and examine the vaginal walls and cervix
for lacerations and abrasions.
- Aspirate or collect vaginal secretions on a saline-soaked swab. Sperm
remain motile for about three hours after ejaculation. Non-motile sperm
may be found for up to 72 hours.
- Swab areas involved in oral and anal intercourse, if appropriate. Spermatozoa
have been recovered from the mouth up to six hours after the event-even
after the victim had brushed her teeth or used a mouthwash.
- Carefully seal and date all specimens collected.
Hampton, H.L. (1995) Care of the Woman Who Has Been Raped. New England
Journal of Medicine. 332, 234-7.
ACOG Technical Bulletin Number 172-September 1992. International Journal
of Gynecology and Obstetrics, 1993: 42; 67-72.
To: Resident Directors
From: Administrator, Study Abroad Office
Subject: Medical Confidentiality
It is important to clarify the role of the Resident Director with respect
to medical confidentiality. The Resident Director is responsible for the
safety and security of students and the medical professional in the host
country is responsible for the health and well-being of the student.
Medical confidentiality is important so that students can feel safe to
discuss their medical problems openly with the medical professional. Thus,
for routine student health care the medical professional shall not share
medically confidential information with study abroad staff. However, because
the Resident Director is responsible for overall program management to ensure
a safe and secure environment for students, he or she has a need to know
certain information students safety, security or programs. When such information
is given to the Resident Director, he or she is bound by the Privacy Act
and rules of medical confidentiality.
The Privacy Act protects information about individuals which is maintained
in an agency system of records, including medical information and medical
records. The Act provides a serious criminal and civil penalties for the
unauthorized release of information contained in a protected file.
The Privacy Act authorizes the release of certain information by the
keeper of the record to another agency employee on a need to know basis.
The Resident Director has a legitimate need to know certain information
in order to properly perform his or her duties.
For example, in the case of any physical or sexual assault, the Resident
Director must be given timely notification that an incident has occurred,
the type of assault, where it occurred, the date and time of day it occurred,
whether the assailant was known, whether there was more than one assailant,
whether any weapons were involved, and any other information which pertains
to the safety and security of that student or other students. This is an
extension of medical confidentiality to the Resident Director based on a
need to know in order to carry out his or her responsibilities.
There are no circumstances in which extension of medical confidentiality
to the Resident Director may be appropriate. These include situations in
which there is a serious threat to student health and safety. Examples of
these situations may include life threatening communicable diseases; child
or spouse abuse; drug use; potential suicide or psychotic or violent behavior;
alcohol abuse if it impairs the students health, safety, or ability to perform
effectively; or any other condition or situation that would prevent a student
from attending class. Only information that affects the well-being, safety,
and security of the student or other students needs to be shared with the
The guidelines provided describe the nature and extent of the confidential
relationship that exists between student and medical doctor. The limitations
on medical confidentiality and the extension of medical confidentiality
to non-medical staff are also outlined.
The purpose of medical confidentiality is to ensure that the patient
can be completely open with his or her health care provider and not withhold
important information for fear that it will be released to others who do
not have a need to know. Responsible handling of confidential and private
medical information obtained by the health care provider during a course
of diagnosis or treatment of a student is an important part of an effective
student health program.
In addition to medical confidentiality, the Privacy Act
protects information about individuals, which is maintained in an agency
system of records. The medical information maintained about a student is
a protected Privacy Act record.
C) MEDICALLY CONFIDENTIAL INFORMATION
To be covered by medical confidentiality, information must be of a medical
nature about an individual student and must be held by a medical provider
(except when medical confidentiality has been extended to a non-medical
personnel as discussed in Section 5.) Medical information shared by a student
with a non-medical staff is not medically confidential.
The following types of information are considered medically confidential:
- Medical records. All medical records must be stored in a locked file
cabinet with access limited to medical unit personnel.
- Information of a medical nature obtained from the student by a health
- Cables, faxes, or telexes marked medically confidential or "Med
D) SHARING NON-CONFIDENTIAL INFORMATION
The following situations are examples of cases where, without revealing
the underlying medical information, the doctor would appropriately share
information with the Resident Director, or designee, and others who have
a programmatic need to know about a student's status.
- When a student will be absent due to illness or injury, program staff
need be advised of the student's absence and projected return.
- If limitations on activity would impair the student's ability to function
as a student.
- During a medical evacuation, program staff need information on the
probability of return to country.
- Behavioral problems are usually of concern to all staff and can be
discussed in terms of the observed behavior and potential risk to the student
E) EXTENSION OF MEDICAL CONFIDENTIALITY
Medical confidentiality may be extended to non-medical personnel in any
of the following circumstances. Persons with whom confidential medical information
is shared are required to protect the information in the same way as medical
The student has authorized in writing the release of some or all of his/her
If, in the opinion of the doctor, failure to release the information
would pose a significant threat to the life or physical safety of the student
or others, or if the doctor believes a student is likely to be threat to him/herself
or the physical safety of others, or the program, the doctor should extend
medical confidentiality to non-medical staff and share any information concerning
the condition, diagnosis, or treatment of the student that is appropriate
to the role and responsibilities of the other staff. Examples may include
life-threatening communicable diseases, child or spouse abuse, drug abuse,
or potential suicidal or violent behavior.
The Resident Director must be notified immediately when a student has
been physically or sexually assaulted. This notification must include the
- Type of assault.
- Date and time of day and the name of the town or city the assault occurred
(and whether it occurred on the study center).
- Whether the assault was related to the program.
- Whether assailant was known.
- Whether there was more than one assailant.
- Whether a weapon (s) was involved.
- Any other information concerning the safety and security of this or
The Resident Director's need to know the name of the student depends
upon the situation. When the Resident Director believes that there is a
need to know the name of the student, providing the name to the Resident
Director is appropriate.
Staff at the study center may need to know or may be able to surmise
confidential information from circumstances surrounding an incident or medevac.
In such cases, they are also bound by the rules of confidentiality and privacy.
F) INQUIRIES FROM FAMILY MEMBERS AND OTHERS
When authorized by the student, confidential medical information may
be released to family members or others. Written authorization should be
obtained and filed in the student's health record. In cases where it is
not possible to get written documentation, verbal authorization must be
documented by the doctor in the health records. Even when faced with concern
expressed by family and friends, confidentiality of medical information
must be ensured.
Notification of a student's condition without the student's consent may
be made only by Resident Director in cases where a student is incapable
of providing consent and is considered to have a serious or life threatening
condition. Notification is made to the individuals whom the student designated
in writing for notification in case of emergency.
G) MEDICAL CONFIDENTIALIY IN COMMUNICATIONS
Communications which identify an individual student and contain medical
information should receive the "Medical Eyes Only" designation.
Cables are more secure than the telephone or the fax. Telephone transmissions
and fax transmission can be intercepted and understood by a third party.
Cables are encrypted, so that they may not be understood if intercepted.
A cover sheet indicating that medically confidential information follows
should be used in all transmissions.
Doctors should be able to conduct telephone conversations without being
overheard so that student's privacy and confidentiality can be maintained.
To provide guidance in meeting the emotional needs of students who have
been sexually assaulted. The vast majority of sexual assaults are assaults
on women, and for the purposes of this guideline it is assumed that the
victim is a women. The same principles should be used when responding to
a sexual assault on a man.
"Management of Sexual Assault", provides background information
concerning sexual assaults and describes the medical and legal procedures
appropriate in managing reported assaults. This guideline provides more
specific information on the emotional support of victims of sexual assaults.
C) PREVENTION AND PLANNING
The medical doctor has a responsibility to the student to assist them
in preventing sexual assaults by including the following topics in Pre-departure
orientations and on-site orientations.
- Students should be informed about when and where sexual assault is
more likely to occur. The institution could consider keeping information
on these types of incidents on a database.
- When threatened with sexual assault, the initial response is an individual
decision and may include verbal tactics such as conversation, joking, or
screaming; and physical actions such as struggling, biting, or kicking.
- A review of cultural do's and don'ts can help students understand what
might make them targets for attack. The review may include discussions
on behavior in the street, manner of dress, and areas to avoid (for men
- Students can learn from watching host country women handle various
forms of harassment such as unsolicited verbal comments, facial expressions,
gestures, touching, and fondling. For some students, attitudes and behaviors
will need to change significantly to avoid and/or cope with harassment.
The medical doctor should identify local physicians and trained counselors
available for managing cases of sexual assault. Staff members should agree
on how medical confidentiality should be preserved and student privacy respected.
D) INITIAL RESPONSE TO A SEXUAL ASSAULT
After a sexual assault, the student may seek out someone she trusts and
from whom she expects to receive support. All staff should be trained to
fulfill this role. Students who report a rape or other serious assault should
not be left unaccompanied.
The emotional and physical needs of the victim should be attended to
immediately. For serious assaults, the designated medical doctor should:
- Assure the student of her physical safety.
- Provide psychological support through a warm, non-judgmental approach.
- Help the student identify people and things that she would find supportive
- Offer calm acceptance of the student's range of feelings, and reassure
her that these are normal reactions to trauma.
- After obtaining consent, record the medical history, perform a physical
examination and evaluate the student's psychological condition. Refer to
"Management of Sexual Assault." Medevac is generally recommended,
but may not be immediately accepted by the Student (see below.)
- Suggest a warm bath or shower and a change of clothes (after the appropriate
physical evaluation has been completed.)
Students who are sexually assaulted may be reluctant or unwilling to
report the assault. Reasons for this reluctance include guilt, denial, shame,
distrust of staff, and concerns about confidentiality. Reporting is more
likely to occur if the assailant is a stranger or if the student is injured
as a result of the assault. Assault reporting is important both to provide
care and support for the victim and to assist other students through the
in-country safety program.
E) RECOVERY FROM SEXUAL ASSAULT
The recovery from sexual assault may be long and complicated. To assist,
the designated medical doctor should:
- Continue to help the student work through the experience by offering
emotional support. Suggest professional counseling as appropriate.
- Offer medical evacuation for counseling, recuperation, consideration
of withdrawing from the program or preparation to return to country. This
brief return to one's own culture greatly facilitates the healing and emotional
reorganization. Medical evacuation should be encouraged.
- Assist her in making her own decisions. She needs to regain control
of her life, starting with the small decisions, such as what to take home
- Gradually begin to discuss options with her.
Does she want to go home for additional medical or psychological support?
Does she want her family or friends notified?
Is there another student in the program able to provide companionship and
support who should be notified?
Are there any concerns about returning to her program?
- Offer support to the students who may be experiencing guilt, anger,
- Recognize that the sense of belonging to the program can be therapeutic.
- Be aware that there is the potential for an anniversary reaction the
F) PSYCHOLOGICAL COUNSELING
The psychological condition of the student should be evaluated at all
visits. Encourage the student to talk. Listen carefully and notice how she
acts. Her body language will give clues as to how she feels. Following are
suggestions for helping the student talk about her experience.
- Encourage her to tell you what happened. Start with general questions
and gradually move to more specific ones. These might include questions
about the circumstances before, during and after the assault, the assailant,
any conversation that took place, the sexual details, physical and verbal
threats, whether there was a struggle, alcohol or drug use (by assailant
or student) and her reactions. Find out about her social network and whether
she has been supported or not.
- Empathize and do not blame. Blaming and judgmental attitudes greatly
interfere with the helping process. She needs and deserves confirmation
that she has been assaulted. Support the fact that she was victimized.
- Share her pain. Let her know she's no longer alone. It will emotionally
- Encourage her to keep talking. Through it she will gain perspective
and help herself. If she is not verbal and her style of expression is hard
to understand, try to avoid getting frustrated-silence communicates, too.
Allow periods of silence.
- Let her cry if she needs to. This is a grieving process. She's been
hurt and has lost a sense of safety and security and thus a way of life.
That is a severe loss.
- She will need to hear that it wasn't her fault. Assure her that she
can get through this. If she took risks, assure her that she can avoid
risks in the future.
- Encourage her to express all feelings regarding the assault, the assailant,
and the situation. Assist her in clarifying and defining these feelings
which may be overwhelming. Assure her that her feelings are the understandable
reaction to such as trauma.
- Recognize her fear and respect it. She needs it, especially if threatened.
It is real.
- Recognize her rage and help her to identify and respect it. Rage at
being important and helpless should be directed toward the assailant and
not toward herself (i.e. self-blame and recrimination.) It may be slow
incoming because it is usually constricted. To assist, you may need to
help her express anger at the assailant.
- Know that it will take time for her to get over this, but that she
can learn to live with it. Tell her this.
- Recognize and support her strength every step of the way (e.g., her
coping mechanisms during the assault, her getting help.)
G) LONG-TERM EMOTIONAL REACTIONS
Reactions to sexual assault vary. However, there are several common ones
that may recur for weeks or even months after the attack. These include:
- Fear of remaining in the same residence or site.
- A need for continuous support from family or close friends.
- Difficulty in sleeping, recurrent nightmares, intrusive thoughts about
- Fear that the assailant will return.
- Fear of crowds but also fear of being alone.
- Fear of being either indoors or outdoors, depending on where the rape
- Fear of sex or lack of sexual desire.
- Periods of depression or anger.
- Feelings of guilt.
- Feelings of being damaged or unclean.
- Feelings of paranoia that other people are talking about her or laughing
- Feelings that she can't trust anyone, particularly men.
The student should be assured that her feelings are normal. She should
be encouraged to regain control of her life. As she does so she should begin
to experience a lessening of her fears and begin to accept that the rape
has occurred and that it can be placed in perspective along with other bad
things that occurred in her life.
Many students are worried about what to say and how to handle the reactions
of people who know about their experience. The utmost care must be taken
in observing medical confidentiality requirements.
The designated medical doctor should be aware of his or her own response
to the student who has been sexually assaulted:
- One common response is denial, downplaying the trauma, and telling
the student that things really aren't so bad.
- Another common response to a student is to focus on what went wrong,
what she might have done differently or what mistakes she made. Explain
to the student that people who respond in such a way probably do not mean
to judge as much as they need to deal with their own anxiety about the
- Some may respond with criticism or judgment of the student. In particular,
some men may be dealing with their own anxiety about the aggressive use
of sexuality by members of their own sex. Men who are able to respond with
sensitivity and understanding may have particularly helpful effect in providing
(Adapted from the Peace
Corps Volunteer Safety Council, January, 1998)